1700639770 NPI number — IMAGO DEI SUPPORT SERVICES. LLC

Table of content: (NPI 1700639770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700639770 NPI number — IMAGO DEI SUPPORT SERVICES. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMAGO DEI SUPPORT SERVICES. LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700639770
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12531 CLIPPER DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22192-2355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-218-2595
Provider Business Mailing Address Fax Number:
804-714-0023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12531 CLIPPER DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22192-2355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-427-2710
Provider Business Practice Location Address Fax Number:
804-714-0023
Provider Enumeration Date:
04/09/2024

Additional Information

Authorized Official

Authorized Official Last Name:
GBADEBO
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
804-218-2595

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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